IntraPet Ultrasound Patient Information Form

IntraPet Patient Information

Text 410-849-6867 or intrapetstaff@gmail to schedule
Please contact us by text or email with your requested dates, including add-ons, if you have not already done so 🐾 Thank you!
Date of confirmed Ultrasound Exam * LEAVE BLANK IF NOT CONFIRMED by IntraPet

Month Day Year
Hospital Name *
DVM Name
Pet Name *
Owner Last Name
Date of Birth *

Month Day Year
Date
Weight (specify lbs or kg) *
Species/Breed *
Sex *
Previous IntraPet Ultrasound? *
Date of Previous IntraPet Ultrasound
Ultrasound Exam (multiple may be selected) *

Abdominal Echocardiogram (Heart, NOT Chest) Specialty-Chest, Urinary, Thyr, Preg Procedure-FNA, ECG, OTHER
DVM/EMPLOYEE PET *

YES NO
Please specify type of Special procedure if applicable
Presenting Complaint/History/PE *
Medications (Current dose & Duration)
Lab Results/Radiograph Findings (Brief description, please email intrapetstaff@gmail full results)
Tentative diagnosis/ Questions to be answered with ultrasound
Special instructions, concerns
Please provide pre-calculated IV sedation dosages to be used in the event they are necessary to achieve a full diagnostic ultrasound. If sedation is deemed necessary by the Sonographer despite best efforts to avoid it, due to abdominal wall tension or excessive patient movement, and dosages are not available or if they are declined, a partial scan will be performed and a full scan charge may apply. Please note, we do NOT REQUIRE sedation, it is a choice made by dvm and owner. Please contact us if sedation recommendations are needed from our specialists (*certain sedatives interfere with echocardiograms, please contact us with any questions)
Sedation

YES, IV sedation is approved and will be used if deemed necessary YES, IM sedation is approved and we will contact IntraPet to discuss timing* NO, sedation is declined
* Intramuscular injection does not allow us to assess the patient prior to the scan, it must be given before we are in the clinic. Please text us the morning of the scan to avoid a possible fee.
Sedation dosages (note IV or IM) *
(OR TYPE “SEE MEDICAL NOTES” , “DECLINED” IF APPLICABLE
SCHEDULING *

YES, we have contacted IntraPet to schedule/confirm, including add-ons NO, we have not contacted IntraPet to scheudule and will do so after form submission (this form submission does NOT schedule your exam, including add-ons)
ATTENTION!

your form submission will auto-delete by midnight if we have not received a text/email from the you to schedule
Your Email to receive a PDF copy of this form for your records *
example@example.com
QUESTIONS? TEXT/CALL 410-849-6867 or EMAIL intrapetstaff@gmail
Should be Empty:

IntraPet Patient Information

Please contact us by text or email with your requested dates, including add-ons, if you have not already done so 🐾 Thank you!